title: Stage of hilar cholangiocarcinoma predicts recurrence of biliary obstruction in patients with metal stents.
abstract: OBJECTIVE
  Most patients with hilar cholangiocarcinomas present with unresectable tumors, so only palliative biliary drainage with self-expanding metal stents (SEMS) is possible. Stents eventually cease to function because of tumor overgrowth and/or other causes, so it is important to identify factors that affect stent patency and failure. We examined the patency of endoscopically placed SEMS in patients with hilar cholangiocarcinoma and factors associated with patency.
  
  
  METHODS
  We performed a retrospective study of 120 consecutive patients (mean age, 67 ± 14.6 years; 74 male) who presented with obstructive jaundice from hilar cholangiocarcinoma and underwent bilateral SEMS from September 2006 through April 2012 at 2 US tertiary medical centers. We collected data on patient demographics and survival, success of stent placement and function, and immediate adverse events. The primary outcome was duration of stent patency (time from insertion to failure).
  
  
  RESULTS
  Thirty-eight patients had stage 1 hilar cholangiocarcinomas, 45 had stage 2, 12 had stage 3, and 25 had stage 4. The median length of the hilar stricture was 9 mm (range, 8-50 mm). The stent was successfully passaged across the stricture in all patients and was functional in 115; its median length was 8 mm (range, 8-10 mm), and diameter was 80 mm (range, 60-100 mm). Fourteen patients had immediate adverse events, including perforation (n = 2), bleeding (n = 2), pancreatitis (n = 9), and cholangitis (n = 1). Median survival was 17 weeks (range, 1-211 weeks), and 50 patients had stent occlusion. On Kaplan-Meier analysis, the median time from stent placement to occlusion was 17 weeks (range, 1-104 weeks). More patients with stage 3 or 4 tumors (64%) had SEMS occlusion than patients with stage 1 or 2 tumors (28%) in univariate analysis (P = .017). In multivariate analysis, only cancer stage was independently and significantly associated with patency (P = .006; hazard ratio, 2.77); age, sex, length of stricture, and SEMS diameter and length were not.
  
  
  CONCLUSIONS
  The cumulative patency of bilateral SEMS for hilar cholangiocarcinoma significantly decreases as tumor stage increases. Age, sex, length of stricture, and SEMS diameter and length are not associated with SEMS patency.
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
authors.forename: Ali
authors.initials: A
authors.lastname: Siddiqui
authors.forename: Haroon
authors.initials: H
authors.lastname: Shahid
authors.forename: Avik
authors.initials: A
authors.lastname: Sarkar
authors.forename: Kristen
authors.initials: K
authors.lastname: Cox
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Kowalski
authors.forename: David E
authors.initials: DE
authors.lastname: Loren
authors.forename: Ashish
authors.initials: A
authors.lastname: Sharma
authors.forename: Patrick
authors.initials: P
authors.lastname: Laing
authors.forename: Madeline
authors.initials: M
authors.lastname: Birch
authors.forename: Douglas G
authors.initials: DG
authors.lastname: Adler
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018281:Cholangiocarcinoma / Q000150:complications* / Q000473:pathology* / Q000601:surgery; D002779:Cholestasis / Q000453:epidemiology* / Q000209:etiology* / Q000601:surgery; D006801:Humans; D008113:Liver Neoplasms / Q000150:complications* / Q000473:pathology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012008:Recurrence; D012189:Retrospective Studies; D015607:Stents; D017211:Treatment Failure; D014481:United States
keywords: ERCP; Efficacy; HC; Liver Cancer; SEMS; Technical and Functional Success; Treatment; endoscopic retrograde cholangiopancreatography; hilar cholangiocarcinoma; self-expanding metal stent